Sabotaging Success:

Sabotaging Success:

Feature Sabotaging Success: The Role of Unconscious Bias Angela S. Prestia, PhD, RN, NE-BC The nurse leader may be unaware of the role unconscious bi...

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Sabotaging Success: The Role of Unconscious Bias Angela S. Prestia, PhD, RN, NE-BC The nurse leader may be unaware of the role unconscious bias plays in the success or failure of an organization. The subtlety of this prejudice may affect a leader’s perception and influence professional judgement and decision making in the areas of communication, hiring, promoting, or team selection. This article explores types of unconscious bias and offers the nurse leader practical advice for minimizing their detrimental effects.


xecutive nurse leaders seek to find the elusive mark of excellence distinguishing their team’s care as superior and patient-worthy. They lead multiple efforts to achieve accreditations and designations that they hope will be the differentiating factor for nurse retention, physician affiliation, and patient selection. Difficult to achieve, these accolades may be even more elusive to sustain. Leadership attrition, regulation nuances, and financial priorities often derail stellar programs. Team composition is also critical to the success of any project. Selecting the correct personnel for project responsibility is often done quickly and without intention. Leaders develop repertoires of ideas as well as “favorite” individuals with proven implementation track records. However, often these resources cannot be universally applied and project failures surprisingly occur. The creation of multifaceted diverse teams are essential to innovating solutions to challenges that have never before existed in the health care arena.1,2 Leaders may consciously understand the importance of diverse team composition, yet unconsciously sabotage efforts to create such cohesion; as they fall victim to biases so deeply buried, they effect discretion and grossly influence professional judgement.3 Unconscious bias can effect a leader’s perception and attitude causing errors in decision making.4 The purpose of this article is to acknowledge the existence of unconscious bias, examine why it occurs, explore the different types, and provide nurse leaders with practical advice for minimizing and eradicating it as a detrimental force in creating and sustaining healthy work environments. BACKGROUND The literature reviewed for this paper reinforces the fact that professionals are unaware that unconscious bias exists and influences decision making. It is found in multiple health care settings and specialties, that is,

academia and practice.3-6 It permeates effective communication, the hiring process, promotional pathways, and team member selection, and creates generalizations related to trustworthiness, motivation, job performance, and individual likability.2,7-9 Victims of unconscious bias can become discouraged and exhibit poor employee performance, diminished commitment, and decreased job satisfaction.7 It can create tension that affects a culture of care. Unconscious bias evolves from the instinctual nature of species survival. It is closely associated with the brain’s ability to detect danger. It ensures the safety of the individual.10 Consider if you will our ancestors’ experiences with wild animals or unfamiliar tribes. The ability to avoid or mitigate serious consequences is experiential and becomes ingrained in the subconscious. Through the generations, cultural and societal factors continue to influence how children are socialized. Subliminal messages are sent via advertisements. Social media and social affiliations effect what and how information is received and often times processed.3 There is natural chemistry with individuals who are most like ourselves.4 Executives subconsciously want to KEY POINTS  Biases deeply ingrained may effect nurse leader discretion and influence professional judgment.  Unconscious bias can be found in operational areas of communication, hiring, career advancement, and team member selection.  Combating unconscious bias begins with raising its awareness, educating staff, and implementing specific inclusionary processes. Month 2019


Table 1. Types of Unconscious Bias Type of Bias

Description of Bias

Example of Bias

The subconscious connection based on a common bond

Shared enjoyment of golf, fishing, children, live theatre

Comparing or recognizing a likeness

Share the same religion

Attribution bias

Places blame on others or external reasons for failure

“I wasn’t given the resources I needed to complete the project.”

Confirmation bias

Occurs with a judgment we then seek validation for

“See, I knew that she could not make the leap from for-profit to not-for-profit.”

Admiring physical attributes as a measure of success

Tall CEOs are more successful than short CEOs

Halo bias

Creating esteem for an individual based on a singular achievement

Harvard graduate so must excel at everything

Horn bias

One miss-step clouds a person’s chances forever

“4 years ago, she failed at a project, so she should not be considered for a promotion.”

Comparing a person to the one who came before, such as a previous CNO or previous applicant

“This last candidate we interviewed had a much more creative answer to how she would innovate change.”

Going along with the majority of the group and not voicing a different opinion

“I agree, as a single parent, he may call off frequently.”

Affinity bias Similarity bias

Beauty bias

Contrast bias

Conformity bias

CEO, chief executive officer; CNO, chief nursing officer. Adapted from Pratt.6 affiliate with those they have a common bond with. There is a tendency to hire, promote, and rely on individuals that are similar and pose no subconscious threat. Types of Bias Unconscious bias can cause prejudicial behavior based on race, gender, sexual identification, culture, religion, or generational differences. There are abundant anecdotal examples within our profession. For example; male nurses should not work in obstetrics, nurses with young children will use more sick time than those without, and women leaders are more emotional than their male counter parts. Additionally there is research to support that some of these biases clearly impact group norms. In medical academia, 5% of women are full professors compared with 18% of their male counterparts.5 There are data to support the informal introduction of female physicians versus the use of formal titles to introduce male physicians. Formal titles are used for female physicians 49% of the time, whereas their male counterparts are introduced by title 72% of the time.11 Consider if you will that women account for 78.4% of the health care labor force yet only 14.6 percent are executive officers and 2

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12.4% hold board positions.12 Women are underrepresented in health care leadership positions. When contemplating this subject and its effects on goal attainment within an organization, several more subtle categories of bias have been identified. They are affinity, similarity, attribution, confirmation, beauty, halo, horn, contrast. and conformity.3 A description and an example of each of these 9 biases is included in Table 1. Micro-inequities can also contribute to the derailment of projects. Coined by Mary Rowe in 1973, micro-inequities are, “apparently small events which are often ephemeral and hard-to-prove, events which are covert, often unintentional, frequently unrecognized by the perpetrator, which occur wherever people are perceived to be ‘different’.”13,14 Micro-inequities can be exemplified in the unconscious acts such as leaving names off of lists, not introducing people, consistently mispronouncing a person’s name, reading half of a person’s e-mail, and then asking the person about the content later, and spreading “ugly” cartoons. Many times, leaders are unaware of microinequities, as they may have never personally experienced this type of bias. They may not realize the extent to which micro-inequities contribute to the derailment

of projects. The unconscious cumulative effect of microinequities may erode an individual team members’ selfconfidence. Suddenly, this capable staff member is no longer willing to contribute ideas or provide much needed performance feedback to the team. Unconscious bias can be present in all aspects of leadership decision making. Its pervasiveness is evident within the context of hiring, promotion, and career advancement.9 Similarity and affinity bias may contribute to inequities in hiring. The composition of the hiring team may influence the selection of the candidate. This can be attributed to shared commonalities or an instinctual need to maintain a majority.9 Beauty and halo bias may positively influence someone’s ability to receive a promotion. Comparatively, understanding the horn and/or contrast bias may explain nonselection. Similarly, an individual may not be selected for a prestigious assignment or task force due to the conformity, horn, or attribution bias. COMBATING UNCONSCIOUS BIAS Education Combating unconscious bias begins with raising awareness of its existence. Education can begin to inspire behavioral changes. However, an intentional approach to the development and timely revision of content is necessary to maximize the positive effects of training and education.5,10,15,16 Requiring unconscious bias as mandatory education may cause participants to become defensive, thinking they are somehow at fault for the class offering. It is suggested that classes be voluntary to avoid resistant posturing. Messaging should relate to the importance of the topic, with the goal of developing a culture of inclusion. A skilled facilitator could solicit interesting situations, encourage role playing and acknowledge techniques that have successfully decreased the impact of bias in the workplace. Facilitating change Aware leaders recognizing the need for change, have implemented processes related to human resource management and attaining diversity goals.5 Several organization have implemented the use of a “blind” resume to minimize assumptions or prejudice of a candidate.4,8,10 Others work to improve their policies related to annual evaluations and promotions.10 Some suggest adding gender-neutral or more inclusive verbiage to job postings and position descriptions.4,8 Micro-inequities can be countered with the conscious addition of micro-affirmations as part of the cultural vernacular.13 Gracious words, acts of kindness, and fair feedback are some examples. Including unconscious bias as a topic for discussion when mentoring new leaders is also effective.

Innovative thoughts surrounding the impact of unconscious bias include the setting of diversity goals. One organization bonuses their executives on their success at achieving the hiring, retaining, and promotion of women.2 This is 1 example of rewarding measurable results. Others establish a mindset of equality and work toward achieving it.4 This can be exemplified by conducting a debriefing of the process, after the interviews, but prior to the hiring, promotion, or selection of a candidate. Nurse leaders can ask the team for feedback to determine whether any of the biases were in play. This creates an opportunity to rethink and regroup if necessary in an effort to minimize unconscious bias. Understanding the impact diversity has on the success of organizational goals can provide the impetus to adopt some of the practices discussed. A diverse workforce provides variability in skills and problemsolving techniques, and can further cement the loyalty of existing staff.7 Awareness of unconscious bias can impact intentionality of choice; a best practice for nurse leaders to embrace to assure greater organizational success. REFERENCES 1. Prestia AS. The art of leadership diplomacy. Nurs Manag. 2017;48:52-55. 2. Clohisy DR, Yaszemski MJ, Lipman J. Leadership communication and negotiation across a diverse workforce. J Bone Joint Surg Am. 2017;99:e60, 1-5. 3. Pratt S. 9 types of unconscious bias and the shocking ways they affect your recruiting efforts. 2016. https://www. Accessed January 2019. 4. Knight R. 7 practical ways to reduce bias in your hiring process. Harvard business review. 2017. 06/7-practical-ways-to-reduce-bias-in-your-hiring-process. Accessed January 2019. 5. Surawicz CM. Women in leadership: why so few and what to do about it. J Am Coll Radiol. 2016;12(1):1433-1437. 6. Bonomo Y, Zundel S, Martin JH. Addressing unconscious bias for female clinical academics. Intern Med J. 2016;46(4):391-393. 7. Mind Tools. Avoiding Unconscious Bias at Work: Avoiding Accidental Discrimination. Available at: https://www. Accessed January 2019. 8. Knight R. 7 practical ways to reduce bias in your hiring process, Harvard Business Review. Available at: 017/06/7-practical-ways-to-reduce-bias-in-your-hiringprocess. Accessed August 8, 2019. 9. Dupre E. Study Pinpoints How Unconscious Bias Impacts Workplace Diversity. 2016. Available at: https://www. Accessed January 2019. 10. Ross H. Exploring unconscious bias. CDO Insights. 2008;2(5). Available at: UnconsciousBias.pdf. Accessed January 2019. 11. Files JA, Mayer AP, Ko MG, et al. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. J Womens Health (Larchmt). 2017;26(5):413-419.

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12. Warner J. The women’s leadership gap: women’s leadership by the numbers. 2017. Center for American Progress. Available at: women/reports/2014/03/07/85457/fact-sheet-the-women’sleadership-gap/. Accessed January 2019. 13. Rowe M. Micro-affirmations & micro-inequities. J Int Ombudsman Assoc. 2008;1(1):1-9. 14. Brogaard B. Micro-inequities: 40 years later. 2013. Available at: Accessed January 2019. 15. Turner E. If unconscious bias is the root problem, how do we uproot it? Available at: caroline-turner/if-unconscious-bias-is-th_b_11071996.html. Accessed January 2019. 16. Emerson J. Don’t give up on unconscious bias training—make it better. 2017. Available at:


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give-up-on-unconscious-bias-training-make-it-better. Accessed January 2019.

Angela S. Prestia, PhD, RN, NE-BC, is the Regional Patient Care Director at Trustbridge in West Palm Beach, Florida, and Adjunct faculty at The Christine E. Lynn College of Nursing, Florida Atlantic University in Boca Raton, Florida. She can be reached at [email protected]

Note: The author declares no conflict of interest. 1541-4612/2019/$ See front matter Copyright 2019 by Elsevier Inc. All rights reserved.